How Not to Dump a Patient

Tuesday morning, 0205, and I’m in charge. Ricky and Craig push an elderly female patient in a wheelchair through the ambulance doors.

These guys are capable and competent paramedics, by which I mean if they say a patient is sick, I tend to take then at their word. No quibbling and no second guessing. Craig is a bit goofy, wiry-thin, rapidly approaching middle-age; he tends to diagnose patients in the back of his rig and elaborate his conclusions at triage. So he’s acquired the title “Doctor” among some of the emerg nurses —and this isn’t meant to be kindly. But he’s okay, really, he knows his stuff and that’s good enough for me. Ricky is well, Ricky. Younger, early thirties, maybe, good-looking in a solid, conventional way. I don’t mind telling that I’ve carried a small, private torch for Ricky for a couple of years, mostly because he exudes confidence, stability and a sort of farmboy charm: if he weren’t married and I weren’t married and if I were twenty years younger. . . well you get the idea.

Craig pulls up to the Desk and winks at me. “Piece of cake,” he says. “She woke up with abdominal pain, nausea. No vomiting, no diarrhea. CTAS 3. Can we take her around to triage?”

I’m distracted by the psych patient who’s come up to tell me for the fifty-third time about the worms in her brain. I nod agreement, reassure the psych patient that the worms aren’t showing, wash my hands and walk around to triage. Ricky gives me the story: 79 year old, woke up with nausea and abdominal pain, extensive cardiac history, diabetes, hypertension, blah and blah and so on, with a med list as long as your right arm.

I look at the patient.

Patient looks like crap. Tachycardic. Pale, cold, clammy. RUQ pain, yeah, but boys, did you appreciate the audible gurgling or the laboured respirations or even the +3 bilateral ankle and foot edema?

Um, no. Ricky looks embarrassed and Doctor Craig has taken a powder to the paramedics room. Then I get it: they’re trying to dump the patient. In other words, they’re trying to avoid an off-load delay by routing the patient directly through triage (and then to the waiting room) by pretending the patient is less sick than she is. Better, they figure, than waiting with the patient on the EMS stretcher for a bed.

I shake my head. I’ve seen some games from some EMS crews before, like the time a crew dropped at triage a hypotensive rectal bleed passing clots the size of canned hams without a by-or-with-your-leave, or told an inexperienced triage nurse the suicidal ideation wasn’t flight risk. But not from Ricky and Craig. Never.

I don’t even bother doing her vitals. Resus room, I direct Ricky — and in ten minutes, she is catheterized, diurysed, and bipaped. CHF, of course: the RUQ pain was all the blood backing up into her liver.

I am severely annoyed. Not so much they “missed” the presenting complaint — that’s bad enough — but by the assumption I wouldn’t offload an obviously critically ill patient immediately. And they know I’m pissed off. Usually at night paramedics hang out in the emerg as long as reasonably possible, avoiding dispatch, shooting the breeze, trading war stories, flirting with the (much younger) nurses, buying coffee. Socializing. But Craig and Ricky are gone before I can get out of the Resus room to, um, express my concerns.

Craig has been avoiding me all week, and Ricky won’t look me in the eye. I still don’t understand what the rush was about. It wasn’t that busy, and the patient would have been offloaded quickly, regardless.

But I just want to ask them: whatever it was, was it worth losing my trust? Really?